title: Outbreak of acute renal failure in Panama in 2006: a case-control study.
abstract: OBJECTIVE
  In September 2006, a Panamanian physician reported an unusual number of patients with unexplained acute renal failure frequently accompanied by severe neurological dysfunction. Twelve (57%) of 21 patients had died of the illness. This paper describes the investigation into the cause of the illness and the source of the outbreak.
  
  
  METHODS
  Case-control and laboratory investigations were implemented. Case patients (with acute renal failure of unknown etiology and serum creatinine > 2 mg/dl) were individually matched to hospitalized controls for age (+/- 5 years), sex and admission date (< 2 days before the case patient). Questionnaire and biological data were collected. The main outcome measure was the odds of ingesting prescription cough syrup in cases and controls.
  
  
  RESULTS
  Forty-two case patients and 140 control patients participated. The median age of cases was 68 years (range: 25-91 years); 64% were male. After controlling for pre-existing hypertension and renal disease and the use of angiotensin-converting enzyme inhibitors, a significant association was found between ingestion of prescription cough syrup and illness onset (adjusted odds ratio: 31.0, 95% confidence interval: 6.93-138). Laboratory analyses confirmed the presence of diethylene glycol (DEG) in biological samples from case patients, 8% DEG contamination in cough syrup samples and 22% contamination in the glycerin used to prepare the cough syrup.
  
  
  CONCLUSIONS
  The source of the outbreak was DEG-contaminated cough syrup. This investigation led to the recall of approximately 60 000 bottles of contaminated cough syrup, widespread screening of potentially exposed consumers and treatment of over 100 affected patients.
authors.affiliation: Centers for Disease Control and Prevention, Atlanta, GA, USA. erentz@cdc.gov
authors.forename: E Danielle
authors.initials: ED
authors.lastname: Rentz
authors.forename: Lauren
authors.initials: L
authors.lastname: Lewis
authors.forename: Oscar J
authors.initials: OJ
authors.lastname: Mujica
authors.forename: Dana B
authors.initials: DB
authors.lastname: Barr
authors.forename: Joshua G
authors.initials: JG
authors.lastname: Schier
authors.forename: Gayanga
authors.initials: G
authors.lastname: Weerasekera
authors.forename: Peter
authors.initials: P
authors.lastname: Kuklenyik
authors.forename: Michael
authors.initials: M
authors.lastname: McGeehin
authors.forename: John
authors.initials: J
authors.lastname: Osterloh
authors.forename: Jacob
authors.initials: J
authors.lastname: Wamsley
authors.forename: Washington
authors.initials: W
authors.lastname: Lum
authors.forename: Camilo
authors.initials: C
authors.lastname: Alleyne
authors.forename: Nestor
authors.initials: N
authors.lastname: Sosa
authors.forename: Jorge
authors.initials: J
authors.lastname: Motta
authors.forename: Carol
authors.initials: C
authors.lastname: Rubin
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced / Q000453:epidemiology*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000996:Antitussive Agents / Q000032:analysis; D016022:Case-Control Studies; D004196:Disease Outbreaks; D004340:Drug Contamination; D005026:Ethylene Glycols / Q000032:analysis / Q000506:poisoning*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010176:Panama / Q000453:epidemiology; D055815:Young Adult
chemical_list: D000996:Antitussive Agents; D005026:Ethylene Glycols; C013484:diethylene glycol